Operative Laparoscopy Research Articles

Laparoscopic Management of Interstitial Ectopic Using Simple and Safe Technique: Case Series and Review of Literature.

To determine the safety and sustainability of operative laparoscopy in surgical management of cornual and interstitial ectopic pregnancy using a simple and practical method. Case series of five consecutive cases. Endoscopy unit in Alexandria University Hospital and Alexandria New Medical Center. Between July 2013 and May 2015, five women with interstitial and cornual ectopic pregnancies were admitted for laparoscopic surgical treatment. Full medical and surgical histories were taken. We explained all alternatives for both partners before informed. Patients underwent laparoscopy for management of the corneal ectopic. All surgeries were done by the same surgeon (T.S.) with different assistants. We gave different uterotonics drugs to devascularize the uterus. Two or more devascularization sutures were done on each end of the corneal ectopic. We used monopolar and bipolar electrocoagulation when indicated. We did linear cut of the interstitial ectopic with evacuation of the fetus and placental tissues. Extraction of the conceptus was performed through 10mm port. Follow-up of the beta-hCG was done weekly till negative results were obtained. The devascularization sutures together with uterotonics make the surgical treatment of interstitial ectopic easy and safe. This simple technique minimizes blood loss and decreases necrosis that follows excessive use of diathermy. This was demonstrated successfully in different types of interstitial ectopic. We did not remove any part of the uterus during surgery. Clinical criteria of the study cases were discussed. Type, size, blood loss and complications, and duration of the surgery were documented. Operative laparoscopy using sutures and uterotonics is safe and sustainable approach in treatment of interstitial ectopic pregnancy.

Immunohistochemical expression pattern of metastasis suppressors KAI1 and KISS1 in endometriosis and normal endometrium

ObjectiveTo analyze the expression pattern of metastasis suppressors KAI1 and KISS1 in the endometrium of patients with and without endometriosis. Study designIn this pilot study, tissue samples were prospectively collected from 38 patients with endometriosis and 29 without endometriosis, undergoing operative laparoscopy in the proliferative phase of the menstrual cycle; diagnosis or absence of endometriosis was confirmed histologically. Protein expression of KAI1 and KISS1 were analyzed immunohistochemically in endometriotic lesions and the eutopic endometrium of patients with endometriosis and without endometriosis. ResultsKAI1 expression was significantly decreased in the glandular eutopic endometrium of endometriosis patients as compared with that of patients without endometriosis (p=0.008). On the other hand, in endometriosis patients, KAI1 expression was significantly increased in the ectopic as compared with the eutopic endometrial stroma (p=0.021). There were no other significant differences in KAI1 expression between different groups. KISS1 expression in the ectopic glandular endometrium was significantly increased as compared with the eutopic glandular endometrium from patients with (p=0.004) and without endometriosis (p=0.008). There was no significant difference in KISS1 protein expression in the stromal endometrium between the three groups. ConclusionsKAI1 and KISS1 are implicated in the pathogenesis and maintenance of endometriosis. Future studies should investigate whether KAI1 and KISS1 could be used as markers for early and minimally invasive detection of endometriosis based on their differential protein expression pattern in the eutopic endometrium of patients with and without endometriosis.

In-House Night Call Management of Four Ectopic Pregnancies

Background: During the first trimester of pregnancy, ectopic pregnancy is the leading cause of maternal mortality. Diagnosis and management of ectopic pregnancies require that health care providers maintain vigilance. Providing a variety of surgical and medical treatments at night can be challenging to the on call team in a teaching hospital. We present four cases of ectopic pregnancies managed over a 15 hour period by the night on call gynecology team. Cases: Case 1, 26-year-old women diagnosed with a ruptured ectopic pregnancy that required emergent laparotomy and blood transfusion. In Case 2, 27-year-old women underwent dilation, curettage and minimal invasive surgery of operative laparoscopy for ruptured ectopic pregnancy. In Case 3, a 24-year-old woman with unruptured ectopic pregnancy was treated with methotrexate. In Case 4, 35 yearold women underwent minimal invasive operative laparoscopy for unruptured ectopic pregnancy. Conclusion: Despite technological advances in early diagnosis of ectopic pregnancy with the use of transvaginal sonogram and serial β-HCG titers, patients still present to the emergency department with ruptured ectopic pregnancy necessitating acute surgical interventions. This is especially prevalent in inner city hospital catchment area where patients often wait until development of severe symptoms before presenting for medical care. Therefore, diagnosis of ectopic pregnancies warrens a high index of suspicion and treatment plans that are individualized, particularly to area of services with attention to patient

Management and Outcome of Ectopic Pregnancy in a Tertiary Care Center

ABSTRACT Objective To assess the results of management of ectopic pregnancy with respect to maternal morbidity and mortality and to analyze the risk factors. Materials and methods Hospital based cross-sectional study of 52 patients who were diagnosed as ectopic pregnancy in the reproductive age group of 15 to 44 years. Results A total of 62 patients with ectopic pregnancy were identified and studied. The rate of ectopic pregnancy was 1.26:100 deliveries. The mean age was found to be 26 years and majority of them were multigravida (Tables 1 and 2). The most common presenting symptom was abdominal pain (96.15%) (Table 3). Most patients had tubal ectopic pregnancy (94.2%). Ovarian ectopic occurred in two cases and 1 patient had heterotopic pregnancy. Emergency laparotomy was performed in 39 (62.90%) patients, 3 (5.77%) patients received methotrexate injection while 18 (29.0%) patients were managed by operative laparoscopy (Table 5). All cases of laparotomy did not require any further procedure. Out of three cases, 2 (66.66%) cases of medical treatment were successful while only 1 (33.33%) case proceeded to emergency laparotomy. No maternal death occurred. Intensive care unit (ICU) stay was needed in 5 patients. Risk factors were found in 67.3% and most common risk factor was found to be previous pelvic surgeries (56.45%) (Table 6). Heterotopic pregnancy was managed by expectant method. Two patients were of post-intrauterine contraceptive device. Conclusion Although there was no mortality in our study, morbidity was significant which required multiple blood transfusion and ICU admission. High degree of suspicion, early diagnosis using hormonal studies, sonography, and management in an institutional set up can reduce the associated morbidity. How to cite this article Alpana T, Nagarathnamma R, Prasad N. Management and Outcome of Ectopic Pregnancy in a Tertiary Care Center. J Med Sci 2016;2(3):45-47.

Diagnostic and Operative Laparoscopy: Experience in a Teaching Hospital

Diagnostic and Operative Laparoscopy: Experience in a Teaching Hospital

A Modified Technique of Temporary Suspension of the Ovary to the Anterior Abdominal Wall

Our group previously described a technique of temporary suspension of the ovary to the abdominal wall using nylon suture (Abuzeid et al 2002). The aim of this study is to describe a modified simple technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage endometriosis to reduce postoperative adhesion formation.

Right angular pregnancy at seven weeks’ gestation: a case report treated by laparoscopic approach

Angular pregnancy (AP) or implantation of the embryo in the lateral angle of the uterine cavity close to the internal ostium of the fallopian tube is a very rare event. In fact, angular pregnancy refers to implantation of the embryo just medial to the uterotubal junction, in the lateral angle of the uterine cavity. AP must be distinguished, anatomically, from interstitial pregnancy by its position in relation to the round ligament, which crosses the Mullerian duct at the side of the uterotubal junction. AP is associated with a high rate of complications such as bleeding and ruptured uterus due to delayed diagnosis. The authors present a clinical report of AP at seven weeks’ gestation without uterine rupture. They performed directly operative laparoscopy because of acute intra-abdominal hemorrhage. Laparoscopy was useful in the treatment of early angular pregnancy and could avoid the need for invasive surgery or hysterectom.

Robotic surgery in the management of benign complex adnexal masses with a frozen pelvis in women desiring to preserve fertility

Abstract Background: A “frozen pelvis” is a term often used to describe extensive pelvic adhesions. It is considered as one of the most challenging situations that a gynecologic surgeon can face. It commonly is caused by extensive endometriosis and pelvic inflammatory disease. We present two cases with extensive pelvic adhesive disease with the aim to illustrate the value of robotic assisted laparoscopy in the management of benign complex adnexal masses with severe pelvic adhesive disease in women desiring to preserve the fertility. Case 1: A 27 year old female referred to our clinic for evaluation of a complex left adnexal mass. Trans-vaginal ultrasound scan and an MRI suggested bilateral endometriomas. She was noted to have stage IV endometriosis. Da Vinci robot assisted left salpingo-oophorectomy was performed. Case 2: A 43 year old female presented with recurrent episodes of pelvic inflammatory disease following an unsuccessful in vitro fertilization procedure. A trans-vaginal ultrasound scan showed a complex left adnexal mass. She was noted to have extensive pelvic adhesions secondary to chronic pelvic inflammatory disease. Da Vinci robotic assisted left salpingectomy was performed, while preserving the left ovary. Conclusion: Our experience and review of literature suggest that in hands of an experienced surgeon, the inherent advantages of robotic assisted operative laparoscopy makes it a safe and attractive alternative to conventional operative laparoscopy and laparotomy for managing benign complex adnexal masses with concomitant severe pelvic adhesive disease in women desiring to preserve their fertility.

The placental microbiome; microbial presence in nature’s transplant

The placental microbiome; microbial presence in nature’s transplant

Anti-Mullerian hormone trend evaluation after laparoscopic surgery of monolateral endometrioma using a new dual wavelengths laser system (DWLS) for hemostasis

Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to assess the impact on ovarian reserve of the use of dual wavelengths laser system (DWLS) hemostasis after stripping technique of monolateral endometrioma, by dosing the anti-Mullerian hormone (AMH). This prospective study was conducted at the Institute of Obstetrics and Gynecology, University of Foggia, from December 2013 to January 2015. Forty-five women underwent excision of monolateral endometriotic ovarian cyst by stripping without using a bipolar coagulation and performing hemostasis with a DWLS. The AMH serum levels were estimated before the surgery (T0), 4–6 weeks (T1) and 6–9 months (T2) after surgery. Our results suggest that an appropriate surgical technique with the use of laser hemostasis does not determine a significant reduction of ovarian reserve. Laser hemostasis could prevent follicular reserve loss after ovarian endometrioma surgery.

Minimally invasive management of 14–16-week abdominal ectopic with hemoperitoneum: an emergency laparoscopic procedure

Since the first laparoscopic cholecystectomy on a pregnant lady in 1991, a plethora of articles and case studies have been published addressing laparoscopy and their role in pregnancy. The Royal College of Obstetricians and Gynecologists Green-top Guidelines recommends laparoscopic surgery as the preferred approach in early ectopic tubal pregnancies. Laparoscopic versus laparotomy management of abdominal ectopic is a traumatic experience both on physical and emotional levels. The case study was a 36-year-old gravida 2 para 0 patient, previously normal pregnant lady, in which the follow-up ultrasound revealed moderate hemoperitoneum at 14–16 weeks of gestation. Upon urgent diagnostic laparoscopy, massive hemoperitoneum was detected despite no clinical signs of hemodynamic instability. Uterus was found to be within the normal measurements consistent with the nonpregnant state. Multiple myomas were clearly seen in the uterine wall. A fetus of 14–16 weeks was detected attached to the colon during formal laparoscopic pelvic and abdominal exploration for ectopic pregnancy. Operative laparoscopy for abdominal ectopic in skillful hands can be considered a feasible management technique carrying all the advantages of a minimally invasive procedure.

Use of operative laparoscopy in single incision and natural orifice transvaginal surgery.

To the Editor, I read with interest the article titled “Single-incision-two port laparoscopic tubal ligation: A cost comparison and technique description” by Drs Nicel Tasdemir, Remzi Abali, Cem Celik, Erson Aksu, and Didem Akkus. J Turk Ger Gynecol Assoc 2015; 16: 30–1 that was published online on March 1, 2015 (1). The authors compare the traditional 2-port laparoscopy with a single incision using two 5 mm trocars. We had a different experience while using a laparoscope with an operative channel to place a bipolar cautery in tubal ligations; thus, limiting to a one-port laparoscopy. Furthermore, we used a laparoscope with a 6-mm operative channel to place different instruments in single incision (2) and in natural orifice transvaginal cholecystectomies (3). The operative laparoscope is not a new instrument; however, it should not be disregarded and is probably still utilized in many hospitals. It is my opinion that revisiting laparoscopy techniques using this operative laparoscope could further enhance the concepts of minimally invasive surgery.

Effectiveness of laparoscopic surgeries in treating infertility related to endometriosis.

Endometriosis is defined as an illness caused by the presence of foci of endometrial tissue outside the uterine cavity. The illness is found in 5-10% of women at reproductive age. In the group of those suffering from endometriosis, the percentage of infertile women amounts to 50%. At higher stages of endometriosis clinical advancement, the suggested treatment is the application of assisted reproductive technology. The aim of the study was assessment of the effectiveness of laparoscopy in treating infertility related to endometriosis among women treated in our clinic in 2009-2012. The clinic is a medical centre focused on advanced minimally invasive surgical treatment, especially laparoscopic surgeries in diseases of the uterus - with a focus on laparoscopic surgeries for patients with endometriosis of the recto-vaginal area. 53 female patients treated for infertility who underwent a laparoscopic surgical procedure to remove the foci of endometriosis in 2009-2012, were analysed retrospectively. After the surgical procedure, the patients were observed over a period of 12 months, during which the frequency of pregnancies (including natural and assisted pregnancies) was assessed in relation to the stage of endometriosis advancement (rAFS). In 17 out of 53 (32%) patients who underwent the surgical procedure a clinical pregnancy was diagnosed. 11 out of 53 (20.75%) women became pregnant spontaneously, 6 out of 53 (11.32%) patients became pregnant as a result of assisted reproductive technology (ART) (5 IVF and 1 IUI). The average time from the date of surgical procedure to spontaneous pregnancy amounted to 6 months. Laparoscopy is a vital therapeutic method. Operative laparoscopy is an efficient method for treating infertility related to endometriosis, and the procedure seems to be the most effective particularly at stage III rAFS. The period for expectant management after a surgical procedure should last 6 months.

Impact of 3D vision on mental workload and laparoscopic performance in inexperienced subjects

ObjectiveTo assess the effect of vision in three dimensions (3D) vs. two dimensions (2D) on mental workload and laparoscopic performance during simulation-based training. Materials and methodsA prospective, randomized crossover study on inexperienced students in operative laparoscopy was conducted. Forty-six candidates executed five standardized exercises on a pelvitrainer with both vision systems (3D and 2D). Laparoscopy performance was assessed using the total time (in seconds) and the number of failed attempts. For workload assessment, the validated NASA-TLX questionnaire was administered. Results3D vision improves the performance reducing the time (3D=1006.08±315.94 vs. 2D=1309.17±300.28; p<0.001) and the total number of failed attempts (3D=.84±1.26 vs. 2D=1.86±1.60; p<0.001). For each exercise, 3D vision also shows better performance times: “transfer objects” (p=0.001), “single knot” (p<0.001), “clip and cut” (p<0.05), and “needle guidance” (p<0.001). Besides, according to the NASA-TLX results, less mental workload is experienced with the use of 3D (p<0.001). However, 3D vision was associated with greater visual impairment (p<0.01) and headaches (p<0.05). ConclusionThe incorporation of 3D systems in laparoscopic training programs would facilitate the acquisition of laparoscopic skills, because they reduce mental workload and improve the performance on inexperienced surgeons. However, some undesirable effects such as visual discomfort or headache are identified initially.

MP38-07 COMPARISON OF FLEXIBLE URETERORENOSCOPIC LITHOTRIPSY AND RETROPERITONEAL LAPAROSCOPIC URETEROLITHOTOMY FOR TREATMENT OF UNILATERAL LARGE (>15 MM) UPPER URETERAL STONE: A SIX YEAR RETROSPECTIVE STUDY

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2015MP38-07 COMPARISON OF FLEXIBLE URETERORENOSCOPIC LITHOTRIPSY AND RETROPERITONEAL LAPAROSCOPIC URETEROLITHOTOMY FOR TREATMENT OF UNILATERAL LARGE (>15 MM) UPPER URETERAL STONE: A SIX YEAR RETROSPECTIVE STUDY Volkan Tugcu, Selcuk Sahin, Arda Atar, Ramazan Kocakaya, Mithat Eksi, and Ali Tasci Volkan TugcuVolkan Tugcu More articles by this author , Selcuk SahinSelcuk Sahin More articles by this author , Arda AtarArda Atar More articles by this author , Ramazan KocakayaRamazan Kocakaya More articles by this author , Mithat EksiMithat Eksi More articles by this author , and Ali TasciAli Tasci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1382AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are multiple treatment alternative for the management of large, upper ureteral stone. In this retrospective trial, we compared laparoscopic retroperitoneal ureterolithotomy (L-RU) and flexible ureterorenoscopic lithotripsy (F-URS). METHODS Between January 2007 to December 2013, 103 patients underwent L-RU (Group 1) and 80 patients F-URS (Group 2). Indications for the operations were single obstructive or impacted upper ureteral stone, stone size >15 mm. The following parameters of two groups were compared: success rate, auxillary procedure, operative time, blood loss, transfusion rates, duration of analgesia, postoperative pain, hospitalization time, and time to return to normal activities. RESULTS No statistically significant difference in preoperative parameter was found between the two groups except for BMI and stone size. The success rate in a single session of Group 1 (100%) was higher than that of Group 2 (87,5%) (p<00.5). There were 11 auxillary procedures needed in 10 patinets in Group 2. Operative time in Group 1 was significantly shorter than Group 2 (p<0.0001). Duration of analgesia, VAS score, hospital stay, time to return to normal activities in Group 1 was significantly higher than Group 2. CONCLUSIONS For large upper ureteral stones, L-RU and F-URS are safe and effective treatment techniques. Our data showed an advantage of L-RU in high stone clearance rate in a single procedure, lower retreatment rate and shorter operative time compared with F-URS. Table 1. Patient demograhics and preoperative characterictics Laparoscopy (n:103) F URS (n:80) p Mean age (year) 39,9±12,02 40,71±10,22 0,630 Male/Female 73/30 55/25 1 Mean BMI (kg/m2) 25,42±2,5 27,9±1,75 0,0001 Stone size (mm) 21,08±4,49 18,49±3,35 0,0001 Stone side (right/left) 53/50 43/37 0,865 Mean HU CT attenuation 1185,79±140,69 1213,65±224,68 0,306 Table 2. Operative and postoperative data Laparoscopy (n:103) F URS (n:80) p Mean operation time (minute) 65,47±10,92 75±11,56 0,0001 Success rate in a single session (%) 100 87,5 <0.05 Duration of analgesia (day) 4,1±0,86 2,98±1,27 0,0001 VAS 0 5,82±1 4,84±1,43 0,0001 VAS 1 3,88±0,94 3,3±1,28 0,0001 Mean hospital stay (day) 2,94±0,91 1,34±1,37 0,0001 Return to normal activity (day) 8,71±2,17 7,26±0,78 0,0001 Auxilary procedure - 11 (13,75%) Intraoperative DJ insertion 30 45 0,004 Table 3. Complications according to Clavien grading system Complication L-RU (n:103) F-URS (n:80) Action p Clavien grade 1 Ileus 2 - Observation Renal colic 2 4 Analgesics Mucosal injury - 5 Intraoperative ureteral stent placement Ureteral perforation - 1 Intraoperative ureteral stent placement Abdominal distention caused by peritoneal rupture 1 - Observation Subcutaneous emphysema 1 - Observation Clavien grade 2 Fever 2 7 Antibiotics, antipyretics Clavien grade 3a Urinary leak 2 - Ureteral stent placement Clavien grade 3b Ureteral stricture 1 1 Ureteral dilatation + ureteral stent placement Clavien grade 4 Sepsis - 1 ICU referral Total complication 11 19 0,03 Minor complication 8 17 0,016 Major complication 3 2 0,865 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e448-e449 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Volkan Tugcu More articles by this author Selcuk Sahin More articles by this author Arda Atar More articles by this author Ramazan Kocakaya More articles by this author Mithat Eksi More articles by this author Ali Tasci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy

Background/Aims: Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity. Methods: A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a ‘universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status. Results: There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP. Conclusion: Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

English

Purpose of this study is to access the safety and efficacy of direct trocar insertion (DTI) for accessing the abdominal cavity for operative laparoscopy without prior pneumoperitoneum. DTI is one of the safe and effective alternative to veress needle insertion, open access (Hassan's technique) and visual entry systems (disposable optic trocars and endotip visual cannula) in laparoscopic surgery. METHODS: The study included 2480 patients who has undergone laparoscopic procedures at civil hospital, Jalandhar from Nov. 2003 to Sept. 2012 and at Punjab Institute of Medical Sciences (PIMS) Jalandhar from Sept. 2012 to June 2014. Procedures include 2310 laparoscopic cholecystectomies, 148 laparoscopic appendectomies, 10 cases of TAPP Groin hernia repairs and 12 cases of simple ovarian cysts. For DTI, abdominal wall was lifted and trocar was pushed through the fascia and muscle layer. The surgeon felt click when the trocar had pierced the peritoneum and entered the abdominal cavity. RESULTS: Direct trocar insertion was feasible in 100% of patients. There was no evidence of intestinal or vascular injury during trocar placement. Peritoneal access and creation of laparoscopic workspace were attained faster and more efficiently by the DTI technique. CONCLUSIONS: DTI is a fast, safe and reliable alternative to traditional

Effect of two laparoscopic techniques for treatment of ovarian endometrioma on ovarian reserve.

Introduction:Operative laparoscopy is the most common used technique for treatment of patients with ovarian endometriomas, because of many positive effects in comparison with laparotomy. There are many laparoscopic techniques, but most used are cystectomy and puncture with endocoagulation (ablation) of the cyst’s capsule. The aim of this study was to evaluate the effect of two laparoscopic techniques for treatment of ovarian endometriomas on ovarian reserve. We used two ultrasonographic markers for ovarian reserve: ovarian volume and antral follicle count (AFC).Materials and Methods:Sixty patients in reproductive age (18-42 years) were treated for a chronic pelvic pain or infertility in a tertiary hospital (University Clinic for Gynecology and Obstetrics in Skopje, R. Macedonia). The study was prospective and two laparoscopic techniques were used. All patients were with confirmed ultrasound diagnosis for ovarian endometriomas with diameter between 3 and 8 cm. Complete cystectomy was done in 30 patients (group A) and puncture with endocoagulation was done in other 30 patients (group B). Ovarian reserve was analyzed before surgery and was controlled one and three months after laparoscopic surgery.Results:In group A (operated with cystectomy) ovarian volume was 53.46±29.97 cm³ before surgery, which fell to 13.06±7.34 cm³ after one month, and 13.28±7.17 cm³ after three months. Statistical analysis showed a significant reduction in ovarian volume one and three months after surgery (p≤0.01). In group B (operated with puncture and endocoagulation) the ovarian volume was 58.34±37.99 cm³ before surgery, which fell to 18.96±7.90 cm³ one month and 17.38±6.86 cm³ three months after surgery. In both groups there was a significant reduction in ovarian volume one and three months postoperatively (p≤0.01). In the first group AFC was 3.03±1.27 before surgery, 4.8±1.30 one month after surgery and 6.23±1.57 after three months. Statistical analysis showed a significant increase in AFC after laparoscopic cystectomy (p≤0.01). In the second group AFC was 3.07±1.05 before surgery, 5.33±1.60 after one month and 7.0±1.62 after three months. The comparison of AFC showed high statistically significant difference (p≤0.001), e.g. increase of AFC after one and three months in comparison with AFC before surgery.Conclusions:Ovarian reserve decreases after laparoscopic surgery using both laparoscopic techniques. But, this decrease was more frequent using cystectomy in comparison with ablation of the endometriotic cyst.

Evaluation of antimullerian hormone levels before and after laparoscopic management of endometriosis.

Background:Serum antimullerian hormone (AMH) proposed to be a reliable marker of ovarian reserve; the aim of this study was to evaluate the influence and value of laparoscopic management in endometriosis as measured by serum AMH levels.Materials and Methods:In this cross-sectional study, 33 infertile patients who referred to fertility - Infertility Center of Isfahan - with different stages of endometriosis managed by diagnostic operative laparoscopy and serum AMH levels were measured pre and one month postoperative laparoscopy. Main outcome measures were serum AMH levels in correlation with the type of infertility, stage of endometriosis, and type of surgery in infertile patients.Results:33 infertile patients enrolled in the study with mean age 28.9 ± 5 years, and thus did not show a significant difference. Mean serum AMH levels was 4.23 ± 3.75 ng/ml and 2.2 ± 2.47 ng/ml, respectively, in primary and secondary infertility groups before and one month after laparoscopy, which shows a significant difference (P < 0.001). Median AMH level changes in Cauterization (0.67 ± 0.76 ng/ml), endometrioma excision 2 ± 0.6 ng/ml, both 2.18 ± 0.81 ng/ml and shows no significant differences. Mean serum AMH levels were definitely decreased in minimal/mild and severe stage endometriosis before and 1 month after laparoscopy, (1.84 ± 2.06 ng/ml and 2.18 ± 3.45 ng/ml), respectively. Also serum AMH according to ovarian appearance and evolvement showed no significant differences after laparoscopy: (5.5 ± 1.4 ng/ml and 2.76 ± 0.96 ng/ml) and (3.37 ± 2.2 ng/ml and 1.84 ± 1.5 ng/ml).Conclusion:Serum AMH levels clearly decreased 1 month after operative laparoscopy.

Spontaneous Heterotopic Pregnancy: A Case Report

Introduction: Heterotopic pregnancy is the coexistence of intrauterine pregnancy (IUP) and extrauterine gestation. It is a rare and dangerous life-threatening situation that is difficult to diagnose and easily missed. The incidence in the general population is estimated to be 1 in 30,000. Risk factors for ectopic pregnancy are pelvic inflammatory disease (PID), tubo-ovarian abscess (TOA), previous ectopic pregnancies, or previous surgery. Case: A 22 year old gravida 2 para 1-0-0-1 presented to the emergency department (ED) and was diagnosed with heterotopic pregnancy despite lack of any notable risk factors. Transvaginal ultrasound showed live IUP and right ovarian/adnexal ectopic pregnancy with heartbeat, along with moderate hemoperitoneum. She underwent operative laparoscopy and right salpingectomy, being discharged home on post-operative day 1 with a stable hemoglobin concentration. She delivered the IUP at 38 weeks 5 days gestation via spontaneous vaginal delivery. Discussion: This case represents a spontaneous heterotopic pregnancy in a 22-year-old patient with no previous risk factors identified and demonstrates laparoscopy as a successful treatment modality for heterotopic pregnancy.